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Editor's Note:
Darlene Field, PhD, Medscape Neurology & Neurosurgery Scientific Director, discussed the problem of diversion and drug abuse of prescription opioids with James A. Inciardi, PhD. Dr. Inciardi is the Professor and Director, Center for Drug and Alcohol Studies, University of Delaware, Coral Gables, Florida.
Medscape: Can you define prescription drug diversion and describe how and when it occurs?
James A. Inciardi, PhD: Drug diversion is the transfer of a prescription drug from lawful to an unlawful channel of distribution or use. People have been arguing about what diversion is and this is the definition that's been generally settled on. Drug diversion is really the channeling of the drug into an illegal market or illegal use.
Now I will address the second part of that question, how and when does diversion occur? There are so many ways that drugs are diverted. It's kind of mind-boggling and I keep running across new ones. The traditional mechanisms of diversion have been the illegal sales of prescriptions by physicians for what street people call loose doctors and illegal sales by pharmacists. There's also doctor shopping. If you're not familiar with the term, those are individuals who go to numerous physicians having the same complaint to obtain multiple prescriptions. I know of people who have been arrested in various places for having gone to 50 different doctors complaining of pain and asking for some sort of opioid.
Medscape: Then they sell the opioid or they abuse the opioid themselves?
Dr. Inciardi: Well, for most of the doctor shoppers, it's for themselves. They're not dealers. They're dependent on the drug. Then you have theft, forgery, or the alteration of prescriptions not only by patients, but also healthcare workers. I don't know how many doctors' offices I've gone into and I've been left alone in an office and there's a pile of prescription pads there. I have run across 1 individual in Florida who creates prescription blanks with his computer. Then he uses a DEA number from the last legitimate prescription he received.
In addition, there are robberies and thefts from manufacturers, from distributors, and from pharmacies. There are thefts of institutional drug supplies by healthcare workers. Residential burglaries are also a major problem.
I have been in the criminology field for most of my career and I've probably spoken to thousands of burglars over the years. Generally when a burglar breaks into a house these days, he or she looks for 4 things; money, jewelry, drugs, and small electronics. Modern-day burglars go to the medicine cabinets to see what's there. They go into the nightstand next to the beds and see what drugs they can find. In fact, I know of 1 criminal who actually carried around a pocket PDR and would look up the drugs because he didn't want to take anything that he couldn't use because it was more incriminating evidence if he was ever stopped.
In addition to residential burglary, there's cross-border smuggling. Many people are going to Mexico and other countries and coming back with their pockets loaded with drugs that do not require a prescription in those places.
I was talking about the thefts of medications by burglars but there are also medicine cabinet thefts by cleaning and repair personnel in residential settings. There's theft of guest medications by hotel repair and housekeeping staff. If you have to travel with any abusable drugs, take them with you when you leave the hotel room because there's a good chance they won't be there when you come back.
At the pharmacy level, drugs are diverted via shorting, undercounting, and pilferage by pharmacists and pharmacy employees. There's recycling of medications by pharmacists and pharmacy employees.
Medscape: What do you mean by recycling of medications by pharmacists?
Dr. Inciardi: What we found in some of our studies is that there are these pill brokers out there who work with patients and the elderly. The pill brokers will escort the elderly person to a specific pharmacy where they will fill their prescription with a copayment of $5 or $10. The pill broker will pay them $200 for what they got and go back and sell it to the pharmacist for a little bit more. Pills are ′recycled′ that way.
Medscape: Has there been any attempt for the US government to score every pill with a unique number so that they know where these drugs are traveling to?
Dr. Inciardi: Not to my knowledge. However, some drug companies place a computer chip on cases of pills so they can track it as it leaves the manufacturer. But once it gets to the local distributor, I think the process ends there.
We have done rapid assessment studies to try and get really deep into the issue of how diversion occurs and who is doing it. We recently did a study in Wilmington, Delaware, because Wilmington kept showing up in the newspaper as a hotbed for prescription drug abuse.
In our study, we basically sent a SWAT team of sorts, not in the police sense of a SWAT team, but a research SWAT team, into a community for 4 or 5 days to speak to everyone they possibly can, the police, people in the medical field, the health field, and users and dealers. In focus groups with users and in speaking to some of the dealers, one of the things we found out is the elderly are major sources of drug diversion. This is an area where education is really needed because many of the elderly people involved in diversion don't feel that they're breaking the law. They feel that it's their prescription and they should be able to do with it what they want.
For example, an elderly patient will go to their physician and get a prescription for an opioid or something else and go fill it for their low copayment. They will then sell it to the pill broker who, in turn, will sell it a pharmacy or sell it on the street for a much higher price. Some of these diverted drugs are going outside the country.
Medscape: Can you describe the link between prescription drug abuse and crime?
Dr. Inciardi: Researchers have been writing for almost 100 years about the relationship between drug use and crime. Most reported cases of crime relating to prescription drug abuse occur to support a person's own drug habit.
But, of course, there's good money in drug dealing. So many of your burglaries and robberies are occurring for drug dealers to receive their supplies.
Medscape: Are postmarketing surveillance studies an effective way to monitor abuse of pain medications?
Dr. Inciardi: I think they really are because with the postmarketing studies you can find out where the hot spots of abuse are. Then the pharmaceutical company can go into that community or send someone into that community to see what the problem really is and whether it can be addressed. Most of the time, the information tells the pharmaceutical company that they didn't cause the problem, which raises the question of what is the responsibility of the pharmaceutical company. Most of us agree that the pharmaceutical company is responsible to protect the patient. Whether it is their responsibility to protect the abuser is debatable.
Medscape: Have you heard of new formulations of opioids that are abuse deterrent?
Dr. Inciardi: Well, yes I have. As far as I'm concerned, there's no such thing as an abuse deterrent formulation.
You've got a lot of backyard chemists who look for things like this. Given enough time, the backyard chemists will figure out a way to abuse the product. I would give an award to the company that comes up with a truly nonabusable form of opioids.
Medscape: Is there any way that American drug policy can reform to prevent further abuse of opioid-based pain medication?
Dr. Inciardi: No, I don't think there is. We've got the Control Substances Act, which sets up the scheduling and labeling these drugs as Schedule I through V. The problem is these are legal drugs and if the government puts too many controls on them, they will be keeping them out of the hands of the patients who need them. Pain medications are being manufactured for the patients and with the controls that we have on them now, many physicians are reluctant to write prescriptions for opioids.
I think one of the things that is needed is more training in medical school about addictions and opioid drugs. There's a feeling on the part of many physicians that if they prescribe an opioid, they're going to turn their patient into an addict. Addiction can occur, but it's the exception rather than the rule if the dosing is proper and the regimen is correct.I don't think there's much more that can be done in terms of drug policy. I think what the FDA [US Food and Drug Administration] is doing with postmarketing surveillance is a good idea because that gives the pharmaceutical company an idea of where there's a problem, although it's an uneven playing field. The stringent rules that they have for branded medications don't follow through to the generics. I think that's a mistake on the part of the FDA.
It should be an equal playing field because there are so many generics out there that are the same as the branded drug that they should be doing some sort of postmarketing surveillance on generics as well.
Medscape: So the final question we have today is what have we learned from trends in highly abused drugs like OxyContin and other opioids in the United States?
Dr. Inciardi: Well, if anything has been learned about the drug problem in this country, it's that patterns of drug-taking and drug-seeking are continually shifting and changing. There are always fads and fashions of drugs of abuse. They seem to come and go. They emerge and then they disappear from the American drug scene. Then others are rediscovered, reinvented, revitalized, repackaged, and recycled. As new drugs become visible, then there's the concomitant media frenzies. I'll never forget when we first saw crack. The politicians were vaulting over one another trying to get their anti-drug message out and get on to the anti-drug bandwagon.
So the question is where did it all begin? I really don't know. But we have been seeing the abuse of prescription drugs, at least in my career, since the late 1960s. So this is nothing really new. The drugs change. Back in the 1960s and the early 1970s, we saw barbiturates and Quaalude. Now it's Xanax and oxycodone and hydrocodone and hydromorphone. And who knows what it will be next year.
So it's constantly shifting and changing because of these fads that occur. I would be willing to bet that 10 years from now we won't be talking about OxyContin and Vicodin. We'll be talking about something else. Those drugs probably will still be abused, but they won't be getting the attention that they are now.
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